Rethinking brief interventions for alcohol in general practice

Adjusting the 15-method to Danish general practice: identification of barriers, facilitators, and user needs

BACKGROUND

The 15-method is an opportunistic screening and brief intervention tool for alcohol-related problems in primary healthcare. A Danish feasibility study of the 15-method indicated that adjustments were needed to improve its contextual fit to Danish general practice. This adjustment process was conducted in two parts. The first part focused on identifying barriers, facilitators, and user needs for addressing alcohol using the 15-method. The second part will address the identified barriers and user needs to finalize a Danish version of the method. This study reports on part one of the adjustment process.

METHODS

Semi-structured individual interviews and focus group interviews with healthcare professionals (n = 8) and patients (n = 5) from general practice in Denmark. Data analysis was conducted using thematic content analysis. The results were condensed into two focus areas that will form the basis for user workshops in part two of the adjustment process.

RESULTS

The main barriers for addressing alcohol using the 15-method were patients and healthcare professionals not having the same agenda, having difficulty opening a conversation on alcohol, and workflow in the practices. Main facilitators included high interpersonal skills, taking the patient's perspective, and good routines and interdisciplinary work. Suggested adjustments and additions to the method included digitalization, visual icebreakers, quotes and examples, and development of a quick guide. The identified focus areas for user workshops were Communication and Material, and Integration to Workflows.

CONCLUSION

Healthcare professionals found the opportunistic screening approach exemplified by the 15-method to be beneficial in identifying and addressing alcohol-related problems. They appreciate the method's structured framework that assists in presenting treatment options. Identified adjustment areas to the 15-method will lay the groundwork for future efforts to develop a finalized Danish version of the 15-method.

Psychometric assessment of the Runyankole-translated Marlowe-Crowne Social Desirability Scale among persons with HIV in Uganda

BACKGROUND

Social desirability can negatively affect the validity of self-reported measures, including underreporting of stigmatized behaviors like alcohol consumption. The Marlowe-Crowne Social Desirability Scale (SDS) is widely implemented and comprised of Denial and Attribution Domains (i.e., tendencies to deny undesirable traits or attribute socially desirable traits to oneself, respectively). Yet, limited psychometric research has been conducted in sub-Saharan Africa, where the prevalence of unhealthy alcohol consumption is high as well as religiosity and hierarchical social norms. To address this gap, we (a) conducted an exploratory study assessing certain psychometric properties of the 28-item SDS (Runyankole-translated) among persons with HIV (PWH) in Uganda, and (b) examined the relationship between social desirability and self-reported alcohol use.

METHODS

We pooled baseline data (N = 1153) from three studies of PWH engaged in alcohol use from 2017 to 2021. We assessed the translated scale's construct validity (via confirmatory factor analysis), internal consistency, item performance, differential item functioning by gender, concurrent validity with the DUREL religiosity index domains, and the association between social desirability and self-reported alcohol use.

RESULTS

Participants had a mean age of 40.42 years, 63% were men, and 91% had an undetectable HIV viral load. The 28-item SDS had satisfactory construct validity (Model fit indices: RMSEA = 0.07, CFI = 0.84, TLI = 0.82) and internal consistency (Denial Domain ΩTotal = 0.82, Attribution Domain ΩTotal = 0.69). We excluded Item 14 ("I never hesitate to help someone in trouble") from the Attribution Domain, which mitigated differential measurement error by gender and slightly improved the construct validity (Model fit indices: RMSEA = 0.06, CFI = 0.86, TLI = 0.85) and reliability (Attribution Domain ΩTotal = 0.72) of the 27-item modified SDS. Using the 27-item SDS, we found that social desirability was weakly correlated with religiosity and inversely associated with self-reported alcohol use after adjusting for biomarker-measured alcohol use and other confounders (β = -0.05, 95% confidence interval: -0.09 to -0.01, p-value = 0.03).

CONCLUSIONS

We detected and mitigated measurement error in the 28-item Runyankole-translated SDS, and found that the modified 27-item scale had satisfactory construct validity and internal consistency in our sample. Future studies should continue to evaluate the psychometric properties of the Runyankole-translated SDS, including retranslating Item 14 and reevaluating its performance.

A Brief Intervention With Instant Messaging or Regular Text Messaging Support in Reducing Alcohol Use: A Randomized Clinical Trial

Importance

Alcohol use is prevalent among university students. Mobile instant messaging apps could enhance the effectiveness of an alcohol brief intervention (ABI), but the evidence is scarce.

Objective

To evaluate the effectiveness of an ABI plus 3 months of mobile chat-based instant messaging support for alcohol reduction in university students at risk of alcohol use disorder.

Design, Setting, and Participants

In this randomized clinical trial, 772 students at risk of alcohol use disorder (Alcohol Use Disorders Identification Test [AUDIT] score ≥8) were recruited from 8 universities in Hong Kong between October 15, 2020, and May 12, 2022. Participants were randomly assigned 1:1 to either the intervention or control group.

Interventions

Both groups received the same ABI at baseline, which consisted of face-to-face or video conferencing with research nurses who delivered personalized feedback based on the participant's AUDIT risk level, along with a 12-page booklet describing the benefits of alcohol reduction and the harmful effects of alcohol on health and social well-being. The intervention group then received 3 months of chat-based instant messaging support on alcohol reduction guided by behavioral change techniques. The control group received 3 months of short message service (SMS) messaging on general health topics.

Main Outcomes and Measures

All outcomes were self-reported. The primary outcome was alcohol consumption in grams per week at 6 months of follow-up. By definition, 1 alcohol unit contains 10 g of pure alcohol. Secondary outcomes at the 6-month follow-up included changes in AUDIT score, weekly alcohol consumption, intention to drink in the next 30 days, drinking frequency and any binge or heavy drinking in the past 30 days, and self-efficacy of quitting drinking. The primary analysis followed the intention-to-treat principle, and linear regression (reported as unstandardized coefficient B) and logistic regression (reported as odds ratios) were used to compare the primary and secondary outcomes between the intervention and control groups.

Results

The study included 772 students (mean [SD] age, 21.1 [3.5] years; 395 females [51.2%]) who were randomly assigned to either the intervention (n = 386) or control (n = 386) group. In the intention-to-treat analysis, the intervention group had lower alcohol consumption in grams per week (B, -11.42 g [95% CI, -19.22 to -3.62 g]; P = .004), a lower AUDIT score (B, -1.19 [95% CI, -1.63 to -0.34]; P = .003), reduced weekly alcohol unit consumption (B, -1.14 [95% CI, -1.92 to -0.36]; P = .004), and less intention to drink (odds ratio, 0.66 [95% CI, 0.47 to 0.92]; P = .01) at the 6-month follow-up compared with the control group. In analyses adjusted for baseline characteristics, interacting at least once with the research nurse on the instant messaging application resulted in lower estimated alcohol consumption in grams per week (adjusted B, -17.87 g [95% CI, -32.55 to -3.20 g]; P = .01), lower weekly alcohol unit consumption (adjusted B, -1.79 [95% CI, -3.25 to -0.32]; P = .02), and a lower AUDIT score (adjusted B, -0.53 [95% CI, -1.87 to -0.44]; P = .01) at 6 months.

Conclusions and Relevance

Results of this randomized clinical trial indicate that mobile chat-based instant messaging support for alcohol reduction in addition to an ABI was effective in reducing alcohol consumption in university students in Hong Kong at risk of alcohol use disorder.

Trial Registration

ClinicalTrials.gov Identifier: NCT04025151.

Brief interventions 2.0: a new agenda for alcohol policy, practice and research

BACKGROUND

Alcohol problems are increasing across the world and becoming more complex. Limitations to international evidence and practice mean that the screening and brief intervention paradigm forged in the 1980s is no longer fit for the purpose of informing how conversations about alcohol should take place in healthcare and other services. A new paradigm for brief interventions has been called for. BRIEF INTERVENTIONS 2.0: We must start with a re-appraisal of the roles of alcohol in society now and the damage it does to individual and population health. Industry marketing and older unresolved ideas about alcohol continue to impede honest and thoughtful conversations and perpetuate stigma, stereotypes, and outright fictions. This makes it harder to think about and talk about how alcohol affects health, well-being, and other aspects of life, and how we as a society should respond. To progress, brief interventions should not be restricted only to the self-regulation of one's own drinking. Content can be orientated to the properties of the drug itself and the overlooked problems it causes, the policy issues and the politics of a powerful globalised industry. This entails challenging and reframing stigmatising notions of alcohol problems, and incorporating wider alcohol policy measures and issues that are relevant to how people think about their own and others' drinking. We draw on recent empirical work to examine the implications of this agenda for practitioners and for changing the public conversation on alcohol.

CONCLUSION

Against a backdrop of continued financial pressures on health service delivery, this analysis provokes debate and invites new thinking on alcohol. We suggest that the case for advancing brief interventions version 2.0 is both compelling and urgent.

Alcohol Dependence, Treatment Seeking, and Treatment Preferences Among Elderly: A Qualitative Study

INTRODUCTION

In Sweden, alcohol consumption has increased among people aged 65 years and older. Among older adults, 2.7% of men and 1.6% of women fulfill criteria for alcohol dependence. The large majority do not seek treatment. Little is known about treatment seeking among older adults with alcohol dependence.

AIM

The aim of this study was to describe elderly's views on alcohol dependence, treatment seeking, and treatment preferences. Possible gender differences will also be explored.

METHODS

Between December 2017 and March 2018, two focus group interviews and 10 individual interviews were conducted, using semistructured interviews. In total, 13 elderly participated. Data were analyzed using the framework approach.

RESULTS

Two themes and five subthemes were identified: (a) "regret and feelings of shame when losing control" consisting of two subthemes, namely, (1) loss of control over your alcohol consumption and (2) regret and feelings of shame, and (b) "taking back control over your life" consisting of three subthemes, namely, (1) becoming aware that you have problematic alcohol use, (2) to seek help for alcohol dependence, and (3) views on treatment options and treatment settings.

CONCLUSIONS

Increased alcohol use was attributed to a decrease in responsibility and belonging. Alcohol dependence was associated with shame and stigma, which was especially strong for women. Preferred treatments were tailored for the individual, rather than to general factors such as age or gender. Moreover, important components of treatment were to be met with respect, continuity, and controlled drinking as a treatment goal. Future research should focus on interventions to reduce stigma and the development of patient-centered treatments.

The effectiveness of workplace interventions for the prevention of alcohol use: A meta-analysis

BACKGROUND AND AIMS

Previous research has pointed to the potential of workplace interventions addressing alcohol consumption. However, there is still no systematic overview of the effects of these interventions. Therefore, we aimed to quantify the effectiveness of workplace interventions addressing alcohol use by conducting a meta-analysis.

METHODS

A systematic literature search for randomized controlled trials of workplace alcohol interventions published between 1995 and 2020 was conducted in five databases. Studies were included if they were performed in the workplace and reported universal or selective interventions aiming for alcohol use reduction. Primary outcomes were any measures of alcohol use. Standardized mean effect sizes were used to calculate the meta-analytic random-effects-model. Additional analyses were carried out to identify potential moderators and to examine the amount of heterogeneity and publication bias.

RESULTS

Twenty studies with 4484 participants were integrated into the meta-analysis. Results revealed a significant overall mean effect indicating a reduction of alcohol use in favor of the treatment group (d = -0.16, 95% CI = [-0.2715; -0.0511]). Heterogeneity within the data structure was found to be moderate to substantial (I2  = 75.9%, Q-test P < 0.001, τ2 = 0.0375). Additional moderator analyses only showed a significant effect for length of measurement period (P = 0.049).

CONCLUSIONS

Alcohol-related prevention programs conducted in the workplace have a statistically significant and favorable effect on alcohol consumption. Although the overall mean effect is considered to be small, it underlines the effectiveness of workplace interventions targeting a reduction in alcohol use.

Mediators of effects of a digital alcohol intervention for online help-seekers: Findings from an effectiveness trial

BACKGROUND

Digital alcohol interventions have been shown to exert effects in helping individuals reduce their drinking. However, little is known about the mechanisms which mediate such effects. The objective of this study was to estimate natural direct and indirect effects of a digital alcohol intervention.

METHODS

This secondary analysis of mediated effects used data from a randomised controlled trial which included individuals with unhealthy alcohol use with access to a mobile phone aged 18 years or older in Sweden. The comparator was basic alcohol and health information. The digital intervention was centrally designed around weekly monitoring of consumption followed by feedback and tools to support behaviour change. Mediated effects were estimated using measures from 1-, 2-, and 4-months post-randomisation. Primary outcomes were total weekly consumption (TWC) and frequency of heavy episodic drinking (HED). A counterfactual framework was used to estimate three hypothesised mediators: importance, knowledge of how to change (know-how), and confidence.

RESULTS

Between 25/04/2019 and 26/11/2020, 2129 participants were randomised. The intervention improved know-how and confidence, which in turn mediated the effects on TWC and HED at 2- and 4-months. Analyses with imputed data were not markedly different.

CONCLUSIONS

A digital alcohol intervention was found to exert effects in reducing consumption by means of improving individuals' knowledge of how to reduce their consumption and confidence in their ability to reduce. The use of face-valid single item measures is a study limitation notwithstanding observed findings, as is attrition and lack of blinding of participants.

Experiences of a mobile phone delivered brief intervention for hazardous drinking: A qualitative study nested in the AMBIT trial from Goa, India

Background

This study explores the experiences of participants receiving a mobile-based brief intervention (BI) for hazardous drinking in India, to determine characteristics that influenced engagement and examine perceived reasons for change in alcohol consumption.

Methods

Semi-structured interviews were conducted with 10 adult hazardous drinkers who received a mobile-based BI in the intervention arm of a pilot randomised control trial. Data were coded through an iterative process and analysed using thematic analysis.

Findings

Study participants reported a positive experience, with factors such as customised intervention delivery and personal motivation facilitating their engagement. Participants reported a reduction in quantity and frequency of alcohol use. This was credited to the intervention, particularly, its provision of health-related information, goal-setting content and strategies to manage drinking. Apart from alcohol reduction, participants reported improvements in diet, lifestyle, wellbeing, and familial relations.

Implication

By providing a context to explain the impact of the intervention, the learnings from this study can be used to strengthen the implementation of mobile-based interventions. This study outlines the scope for further research in digital health, such as Internet-based health interventions, and incorporating digital interventions within the ambit of existing health care programmes.

Polysubstance Use in Pregnancy: Surveillance, Interventions, and Next Steps

Substance use during pregnancy increases risk for a wide range of adverse maternal and neonatal health outcomes. Polysubstance use is common among people who use substances during pregnancy; however, the risks of combined substance exposures during pregnancy are poorly understood. In this report, we provide an overview of the activities of the Centers for Disease Control and Prevention (CDC) and partners and identified gaps related to (1) surveillance, (2) routine screening, and (3) prevention of polysubstance use during pregnancy. Efforts by CDC and other partners to reduce polysubstance use during pregnancy can improve the health of pregnant people and their infants and children.

'Really putting a different slant on my use of a glass of wine': patient perspectives on integrating alcohol into Structured Medication Reviews in general practice

Background

Alcohol is often overlooked in primary care even though it has wide-ranging impacts. The Structured Medication Review (SMR) in England is a new 'holistic' service designed to tackle problematic polypharmacy, delivered by clinical pharmacists in a general practice setting. Implementation has been protracted owing to the COVID-19 pandemic. This study explores early patient experiences of the SMR and views on the acceptability of integrating clinical attention to alcohol as another drug linked to their conditions and medicines, rather than as a standalone 'healthy living' or 'lifestyle' question.

Method

Semi-structured interviews with a sample of 10 patients who drank alcohol twice or more each week, recruited to the study by five clinical pharmacists during routine SMR delivery.

Results

SMRs received were remote, brief, and paid scant attention to alcohol. Interviewees were interested in the possibility of receiving integrated attention to alcohol within a SMR that was similar to the service specification. They saw alcohol inclusion as congruent with the aims of a holistic medicines review linked to their medical history. For some, considering alcohol as a drug impacting on their medications and the conditions for which they were prescribed, introduced a new frame for thinking about their own drinking.

Conclusions

Including alcohol in SMRs and changing the framing of alcohol away from a brief check with little meaningful scope for discussion, toward being fully integrated within the consultation, was welcomed as a concept by participants in this study. This was not their current medication review experience.

Consultation skills development in general practice: findings from a qualitative study of newly recruited and more experienced clinical pharmacists during the COVID-19 pandemic

OBJECTIVE

The new structured medication review (SMR) service was introduced into the National Health Service in England during the COVID-19 pandemic, following a major expansion of clinical pharmacists within new formations known as primary care networks (PCNs). The aim of the SMR is to tackle problematic polypharmacy through comprehensive, personalised medication reviews involving shared decision-making. Investigation of clinical pharmacists' perceptions of training needs and skills acquisition issues for person-centred consultation practice will help better understand their readiness for these new roles.

DESIGN

A longitudinal interview and observational study in general practice.

SETTING AND PARTICIPANTS

A longitudinal study of 10 newly recruited clinical pharmacists interviewed three times, plus a single interview with 10 pharmacists recruited earlier and already established in general practice, across 20 newly forming PCNs in England. Observation of a compulsory 2-day history taking and consultation skills workshop.

ANALYSIS

A modified framework method supported a constructionist thematic analysis.

RESULTS

Remote working during the pandemic limited opportunities for patient-facing contact. Pharmacists new to their role in general practice were predominantly concerned with improving clinical knowledge and competence. Most said they already practiced person-centred care, using this terminology to describe transactional medicines-focused practice. Pharmacists rarely received direct feedback on consultation practice to calibrate perceptions of their own competence in person-centred communication, including shared decision-making skills. Training thus provided knowledge delivery with limited opportunities for actual skills acquisition. Pharmacists had difficulty translating abstract consultation principles into specific consultation practices.

CONCLUSION

SMRs were introduced when the dedicated workforce was largely new and being trained. Addressing problematic polypharmacy requires structural and organisational interventions to enhance the communication skills of clinical pharmacists (and other health professionals), and their use in practice. The development of person-centred consultation skills requires much more substantial support than has so far been provided for clinical pharmacists.

Alcohol, the overlooked drug: clinical pharmacist perspectives on addressing alcohol in primary care

BACKGROUND

Attempts to routinely embed brief interventions in health systems have long been challenging, with healthcare professionals concerned about role adequacy, legitimacy, and support. This is the first study to explore clinical pharmacists' experiences of discussing alcohol with patients in their new role in UK primary care, in developing a novel approach to brief intervention. It investigates their confidence with the subject of alcohol in routine practice and explores views on a new approach, integrating alcohol into the medication review as another drug directly linked to the patient's health conditions and medicines, rather than a separated 'healthy living' issue. The study forms part of wider efforts to repurpose and reimagine the potential application of brief interventions and to rework their contents.

METHODS

Longitudinal qualitative study of 10 recruits to the new clinical pharmacist role in English primary care, involving three semi-structured interviews over approximately 16 months, supplemented by 10 one-off interviews with pharmacists already established in general practice.

RESULTS

When raised at all, enquiring about alcohol in medication reviews was described in terms of calculating dose and level of consumption, leading to crude advice to reduce drinking. The idea was that those who appeared dependent should be referred to specialist services, though few such referrals were recalled. Pharmacists acknowledged that they were not currently considering alcohol as a drug in their practice and were interested in learning more about this concept and the approach it entailed, particularly in relation to polypharmacy. Some recognised a linked need to enhance consultation skills.

CONCLUSIONS

Alcohol complicates routine clinical care and adversely impacts patient outcomes, even for those drinking at seemingly unremarkable levels. Changing clinical practice on alcohol requires engaging with, and supportively challenging, routine practices and entrenched ideas of different kinds. Framing alcohol as a drug may help shift the focus from patients with alcohol problems to problems caused for patients by alcohol. This is less stigmatising and provides role legitimacy for pharmacists to address alcohol clinically in medication reviews, thus providing one element in the formation of a new prevention paradigm. This approach invites further innovations tailored to other healthcare professional roles.

Effect of two counseling interventions on self-reported alcohol consumption, alcohol biomarker phosphatidylethanol (PEth), and viral suppression among persons living with HIV (PWH) with unhealthy alcohol use in Uganda: A randomized controlled trial

PURPOSE

To test the efficacy of two interventions to reduce alcohol use and increase viral suppression compared to a control in persons with HIV (PWH).

METHODS

In a three-arm (1:1:1) randomized controlled trial (N = 269), we compared in-person counselling (45-70 minutes, two sessions over three months) with interim monthly booster phone calls (live call arm) or twice-weekly automated booster sessions (technology arm) to a brief advice control arm. We enrolled PWH self-reporting unhealthy alcohol use (Alcohol Use Disorders Identification Test - Consumption, prior three months, women ≥3, men ≥4). Primary outcomes were number of self-reported drinking days (NDD) in the prior 21 and biomarker phosphatidylethanol (PEth) at six and nine months and viral suppression (<40 copies/mL) at nine months; we adjusted for sex and baseline outcomes.

RESULTS

At baseline, mean 21-day NDDs were 9.4 (95 % CI: 9.1-9.8), mean PEth was 407.8 ng/mL (95 % CI: 340.7-474.8), and 89.2 % were virally suppressed. At follow-up, there were significant reductions in mean NDDs for the live call versus control arm (3.5, 95 % CI:2.1-4.9, p < 0.001) and for the technology versus control arm (3.6, 95 % CI: 2.2-5.1, p < 0.001). The mean PEth differences compared to the control arm were not significant, i.e. 36.4 ng/mL (95 % CI: -117.5 to 190.3, p = 0.643) for the live call and -30.9 ng/mL (95 % CI: -194.8 to 132.9, p = 0.711) for the technology arm. Nine-month viral suppression compared to the control was similar in the live call and in the technology arm.

CONCLUSION

Intervention effects were found on self-reported NDD but not PEth or viral suppression, suggesting no treatment effect. (NCT #03928418).

Effect of a Novel Brief Motivational Intervention for Alcohol-Intoxicated Young Adults in the Emergency Department: A Randomized Clinical Trial

IMPORTANCE

Heavy drinking among young adults is a major public health concern. Brief motivational interventions in the emergency department have shown promising but inconsistent results.

OBJECTIVE

To test whether young adults receiving a newly developed brief motivational intervention reduce their number of heavy drinking days and alcohol-related problems over 1 year compared with participants receiving brief advice.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted at an emergency department of a tertiary care university hospital in Lausanne, Switzerland. Recruitment ran from December 2016 to August 2019. Follow-up was conducted after 1, 3, 6, and 12 months. All adults aged 18 to 35 years presenting for any cause and presenting with alcohol intoxication were eligible (N = 2108); 1764 were excluded or refused participation. Follow-up rate was 79% at 12 months and 89% of participants provided follow-up data at least once and were included in the primary analyses. Statistical analysis was performed from September 2020 to January 2021.

INTERVENTIONS

The novel intervention was based on motivational interviewing and comprised in-person discussion in the emergency department and up to 3 booster telephone calls. The control group received brief advice.

MAIN OUTCOMES AND MEASURES

Primary outcomes were the number of heavy drinking days (at least 60 g of ethanol) over the previous month and the total score on the Short Inventory of Problems (0-45, higher scores indicating more problems) over the previous 3 months. Hypotheses tested were formulated before data collection.

RESULTS

There were 344 young adults included (median [IQR] age: 23 [20-28] years; 84 women [24.4%]). Among the 306 participants providing at least 1 follow-up point, a statistically significant time × group interaction was observed (β = -0.03; 95% CI, -0.05 to 0.00; P = .02), and simple slopes indicated an increase of heavy drinking days over time in the control (β = 0.04; 95% CI, 0.02 to 0.05; P < .001) but not in the intervention group (β = 0.01; 95% CI, -0.01 to 0.03; P = .24). There was no effect on the Short Inventory of Problems score (β = -0.01; 95% CI, -0.03 to 0.02; P = .71).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that a brief motivational intervention implemented in the emergency department provided beneficial effects on heavy drinking, which accounts for a substantial portion of mortality and disease burden among young adults.

TRIAL REGISTRATION

ISRCTN registry: 13832949.

Brief interventions for alcohol use disorders in low- and middle-income countries: barriers and potential solutions

Global alcohol consumption and harmful use of alcohol is projected to increase in the coming decades, and most of the increase will occur in low- and middle-income countries (LMICs); which calls for cost-effective measures to reduce alcohol exposure in these countries. One such evidence based measure is screening and brief intervention (BI) for alcohol problems. Some of the characteristics of BI make them a particularly appealing choice of interventions in low-resource settings. However, despite evidence of effectiveness, implementation of BI in LMICs is rare. In this paper we discuss barriers to implementation of BI in LMICs, with examples from Latin America and India. Key barriers to implementation of BI in LMICs are the lack of financial and structural resources. Specialized services for alcohol use disorders are limited or non-existent. Hence primary care is often the only possible alternative to implement BI. However, health professionals in such settings generally lack training to deal with these disorders. In our review of BI research in these countries, we find some promising results, primarily in countries from Latin America, but so far there is limited research on effectiveness. Appropriate evaluation of efficacy and effectiveness of BI is undermined by lack of generalisability and methodological limitations. No systematic and scientific efforts to explore the implementation and evaluation of BI in primary and community platforms of care have been published in India. Innovative strategies need to be deployed to overcome supply side barriers related to specialist manpower shortages in LMICs. There is a growing evidence on the effectiveness of non-specialist health workers, including lay counsellors, in delivering frontline psychological interventions for a range of disorders including alcohol use disorders in LMICs. This paper is intended to stimulate discussion among researchers, practitioners and policy-makers in LMICs because increasing access to evidence based care for alcohol use disorders in LMICs would need a concerted effort from all these stakeholders.

Efficacy of a theory-driven program to implement alcohol screening and brief interventions in primary health-care: a cluster randomized controlled trial

BACKGROUND AND AIMS

Screening and brief interventions (SBI) in primary health-care practices (PHCP) are effective in reducing reported alcohol consumption, but have not been routinely implemented. Most programs seeking to improve implementation rates have lacked a theoretical rationale. This study aimed to test whether a theory-based intervention for PHCPs could significantly increase alcohol SBI delivery.

DESIGN

Two-arm, cluster-randomized controlled, parallel, 12-month follow-up, trial.

SETTING

PHCPs in Portugal.

PARTICIPANTS

Staff from 12 PHCPs (n = 222, 81.1% women): nurses (35.6%), general practitioners (28.8%), receptionists (26.1%) and family medicine residents (9.5%); patients screened for alcohol use: intervention n = 8062; controls n = 58.

INTERVENTION AND COMPARATOR

PHCPs were randomized to receive a training and support program (n = 6; 110 participants) tailored to the barriers and facilitators for implementing alcohol SBIs following the principles of the Behavior Change Wheel/Theoretical Domains Framework approach, or to a waiting-list control (n = 6; 112 participants). Training was delivered over the first 12 weeks of the trial.

MEASUREMENTS

The primary outcome was the proportion of eligible patients screened (unit of analysis: patient list). Secondary outcomes included the brief intervention (BI) rate per screen-positive patient and the population-based BI rate (unit of analysis: patient list), and changes in health providers' perceptions of barriers to implementation and alcohol-related knowledge (unit of analysis: health provider).

FINDINGS

The implementation program had a significant effect on the screening activity in the intervention practices compared with control practices at the 12-month follow-up (21.7% vs. 0.16%, intention-to-treat analysis, p = 0.003). Although no significant difference was found on the BI rate per screen-positive patient (intervention 85.7% vs. control 63.6%, p = 0.55, Bayes factor = 0.28), the intervention was effective in increasing the population-based BI rate (intervention 0.69% vs. control 0.02%, p = 0.006). Health providers in the intervention arm reported fewer barriers to SBI implementation and higher levels of alcohol-related knowledge at 12-month follow-up than those in control practices.

CONCLUSION

A theory-based implementation program, which included training and support activities, significantly increased alcohol screening and population-based brief intervention rates in primary care.

Effectiveness of a digital intervention versus alcohol information for online help-seekers in Sweden: a randomised controlled trial

BACKGROUND

The ubiquity of Internet connectivity, and widespread unmet needs, requires investigations of digital interventions for people seeking help with their drinking. The objective of this study was to test the effectiveness of a digital alcohol intervention compared to existing online resources for help seekers.

METHODS

This parallel randomised controlled trial included 2129 risky drinkers with access to a mobile phone and aged 18 years or older. Randomised sub-studies investigated consent procedures and control group design. Simple computerised randomisation was used. Participants were aware of allocation after randomisation; research personnel were not. The digital intervention was designed around weekly monitoring of alcohol consumption followed by feedback and tools for behaviour change. Primary outcomes were total weekly consumption (TWC) and frequency of heavy episodic drinking (HED), measured 2 and 4 months post-randomisation.

RESULTS

Between 25/04/2019 and 26/11/2020, 2129 participants were randomised (intervention: 1063, control: 1066). Negative binomial regression was used to contrast groups, with both Bayesian and maximum likelihood inference. The posterior median incidence rate ratio (IRR) of TWC was 0.89 (95% CI = 0.81;0.99, 98.2% probability of effect, P-value = 0.033) at 2 months among 1557 participants and 0.77 (95% CI = 0.69;0.86, > 99.9% probability of effect, P-value < 0.001) at 4 months among 1429 participants. For HED, the IRR was 0.83 (95% CI = 0.75;0.93, > 99.9% probability of effect, P-value = 0.0009) at 2 months among 1548 participants and 0.71 (95% CI = 0.63;0.79, probability of effect > 99.9%, P-value < 0.0001) at 4 months among 1424 participants. Analyses with imputed data were not markedly different.

CONCLUSIONS

A digital alcohol intervention produced self-reported behaviour change among online help seekers in the general population. The internal and external validity of this trial is strong, subject to carefully considered study limitations arguably inherent to trials of this nature. Limitations include higher than anticipated attrition to follow-up and lack of blinding.

TRIAL REGISTRATION

The trial was prospectively registered ( ISRCTN48317451 ).

2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines

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Reducing problematic alcohol use in employees: economic evaluation of guided and unguided web-based interventions alongside a three-arm randomized controlled trial

AIMS

To perform an economic evaluation of guided and unguided internet-based interventions to reduce problematic alcohol consumption in employees compared with a waiting-list control condition (WLC) with unrestricted access to treatment-as-usual.

DESIGN

A cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) from a societal and a cost-benefit analysis from the employer's perspective with a 6-month time horizon.

SETTING

Open recruitment in the German working population.

PARTICIPANTS

Employees (178 males, 256 females, mean age 47 years) consuming at least 14 (women) or 21 (men) standard units of alcohol (SUAs) per week and scoring ≥ 8 (men) or 6 (women) on the Alcohol Use Disorders Identification Test.

MEASUREMENTS

On-line questionnaires administered to assess SUAs and assess quality of life (AQoL-8D) and resource use. Outcome measure was responder (≤ 14/≤ 21 SUAs) for the CEA and quality-adjusted life years (QALYs) for the CUA. Net benefit regression was used to estimate cost-effectiveness for each study arm. Bootstrapping and sensitivity analyses were performed to account for uncertainty.

INTERVENTIONS

Five weekly modules including personalized normative feedback, motivational interviewing, goal setting, problem-solving and emotion regulation, provided with adherence-focused guidance [n = 142; responders: n = 73 (51.4%); QALYs = 0.364, standard error (SE) = 0.006] or without guidance [n = 146; n = 66 (45.2%); 0.359, 0.007]. Controls were on a waiting-list [n = 144; n = 38 (26.4%); 0.342, 0.007].

FINDINGS

From a societal perspective, the guided intervention had a probability of 55% (54%) of being the most efficient strategy at a willingness-to-pay (WTP) of €0 per responder (QALY) gained, compared with the unguided intervention and the control condition. At a WTP of €20 000 per QALY gained, the probability was 78%. From an employer's perspective, the guided intervention had a higher probability of a positive return on investment (81%) compared with the unguided intervention (58%).

CONCLUSION

A guided internet-based intervention to reduce problematic alcohol consumption in employees appears to be both cost-beneficial and cost-effective.

Danish feasibility study of a new innovation for treating alcohol disorders in primary care: the 15-method

BACKGROUND

The 15-method: a new brief intervention tool for alcohol problems in primary care has shown promising results in Sweden for mild to moderate alcohol use disorders. The present study evaluated the 15-method's usability, organizational integration, and overall implementation feasibility in Danish general practice in preparation for a large-scale evaluation of the method's effectiveness in identifying and treating alcohol problems in general practice.

METHODS

Five general practices in the Central and Southern Region of Denmark participated: seven general practitioners (GPs), eight nurses. Participants received a half day of training in the 15-method. Testing of implementation strategies and overall applicability ran for 2 months. A focus group interview and two individual interviews with participating GPs along with five individual patient interviews concluded the study period.

RESULTS

Results indicate that implementation of the 15-method is feasible in Danish general practice. The healthcare professionals and patients were positive about the method and its possibilities. The method was considered a new patient centered treatment offer and provided structure to a challenging topic. An interdisciplinary approach was much welcomed. Results indicate that the method is ready for large scale evaluation.

CONCLUSIONS

Implementation of the 15-method is considered feasible in Danish general practice and large-scale evaluation is currently being planned.

Effects of a minimal-guided on-line intervention for alcohol misuse in Estonia: a randomized controlled trial

BACKGROUND AND AIMS

Estonia has one of the highest alcohol-attributable mortality rates within the European Union. The aim of this study was to estimate the efficacy of an on-line self-help intervention to reduce problem drinking at the population level.

DESIGN

On-line open randomized controlled trial with an 8-week intervention and an active control group (intervention n = 303, control n = 286). Assessments took place at baseline and at 6 months follow-up.

SETTING

On- and offline channels were used for population-based recruitment within a nation-wide prevention campaign in Estonia.

PARTICIPANTS

Inclusion criteria were age ≥ 18 years, heavy drinking [Alcohol Use Disorders Identification (AUDIT) test score ≥ 8], literacy in Estonian and at least weekly access to the internet; n = 589 participants were randomized (50% male, 1% other; mean age 37.86 years; 45% with higher level of education).

INTERVENTION AND COMPARATOR

The intervention consisted of 10 modules based on principles of cognitive-behavioral therapy and motivational interviewing. The active control group received access to a website with a self-test including personalized normative feedback and information for standard alcohol treatment.

MEASUREMENTS

The primary outcome was AUDIT scores at 6 months follow-up adjusted for baseline scores.

FINDINGS

Intention-to-treat analyses were applied. Missing data were addressed by using baseline observation carried forward (BOCF) and multiple imputation by chained equations (MI); 175 completed follow-up in the intervention group and 209 in the control group. AUDIT score at follow-up was significantly smaller in the intervention [BOCF mean = 13.91, standard deviation (SD) = 7.61, MI mean = 11.03, SD = 6.55] than control group (BOCF mean = 15.30, SD = 7.31; MI mean = 14.30, SD = 7.21), with a group difference of -1.38 [95% confidence interval (CI) = -2.58, -0.18], P = 0.02 for BOCF and -3.26 (95% CI = -2.01, -4.51), P < 0.001 for MI.

CONCLUSIONS

A randomized controlled trial has found that an on-line self-help intervention with minimal guidance was effective at reducing problem drinking in Estonia.

Using qualitative process evaluation in the development of a complex intervention to advance person-centred practice by pharmacists: The Medicines and Alcohol Consultation (MAC)

In order to effectively evaluate complex interventions, there have been calls for the further integration of qualitative methods. Qualitative process studies of brief alcohol interventions and medicines reviews are notably lacking. This article provides a grounded example through the presentation of findings from an embedded qualitative process evaluation of a multi-site, pilot cluster RCT of a new intervention: the Medicines and Alcohol Consultation (MAC). MAC is designed to increase the capacity of community pharmacists (CPs) to conduct person-centred medicines reviews in which the subject of alcohol consumption is raised in connection with medications and associated health conditions. Participant-focused qualitative studies (interviews, observations, recorded consultations) sought to understand how CPs engaged with and implemented MAC in context. This article documents effects of the intervention on developing person-centred consultation practice and highlights how qualitative process studies can be used formatively to develop middle range programme theory and to optimise intervention design for testing in a definitive RCT.

Effectiveness of Screening and Brief Alcohol Intervention at the Workplace: A Study Protocol for a Randomized Controlled Trial at Five Japan-Based Companies

Background

Despite evidence regarding the effectiveness of screening and brief interventions for excessive alcohol use in primary care, these tools are not a part of routine practice. It has been suggested that using these tools at the workplace may be critical to alcohol-associated harm; however, evidence for this claim is unclear. The aim of this article is to develop a study protocol which evaluates the effect of brief alcohol intervention at the workplace to reduce harmful alcohol drinking.

Methods

A randomized controlled trial involving employees (aged 20-74 years) of five Japan-based companies who were screened "positive" by Alcohol Use Disorder Identification Test (AUDIT) is on-going. Participants were randomized into "Patient Information Leaflet" (control group), "Brief Advice and Counselling," and "Five-minute Brief Advice" groups. A self-administered questionnaire was used to assess alcohol consumption, lifestyle behavior, health status, work performance, and consequences of alcohol use. Data of laboratory markers were collected from routine health checkups.

Results

A total of 351 participants were randomized into Patient Information Leaflet (n = 111), Brief Advice and Counselling (n = 128), and Five-minute Brief Advice (n = 112) groups. Participants were mostly men with a median age of 49 years. Median AUDIT score and weekly alcohol consumption were 11 points and 238 g/week, respectively. Two-thirds of the participants were manufacturing workers.

Conclusion

This study protocol developed the first trial in Japan to investigate the effect of brief alcohol intervention combined with a recommended screening tool at the workplace. Our findings can provide evidence on the effectiveness and relevance of these tools to occupational health.

Addressing complex pharmacy consultations: methods used to develop a person-centred intervention to highlight alcohol within pharmacist reviews of medications

BACKGROUND

Alcohol is challenging to discuss, and patients may be reluctant to disclose drinking partly because of concern about being judged. This report presents an overview of the development of a medications review intervention co-produced with the pharmacy profession and with patients, which breaks new ground by seeking to give appropriate attention to alcohol within these consultations.

METHODS

This intervention was developed in a series of stages and refined through conceptual discussion, literature review, observational and interview studies, and consultations with advisory groups. In this study we reflect on this process, paying particular attention to the methods used, where lessons may inform innovations in other complex clinical consultations.

RESULTS

Early work with patients and pharmacists infused the entire process with a heightened sense of the complexity of consultations in everyday practice, prompting careful deliberation on the implications for intervention development. This required the research team to be highly responsive to both co-production inputs and data gathered in formally conducted studies, and to be committed to working through the implications for intervention design. The intervention thus evolved significantly over time, with the greatest transformations resulting from patient and pharmacist co-design workshops in the second stage of the process, where pharmacists elaborated on the nature of the need for training in particular. The original research plans provided a helpful structure, and unanticipated issues for investigation emerged throughout the process. This underscored the need to engage dynamically with changing contexts and contents and to avoid rigid adherence to any early prescribed plan.

CONCLUSIONS

Alcohol interventions are complex and require careful developmental research. This can be a messy enterprise, which can nonetheless shed new insights into the challenges involved in optimising interventions, and how to meet them, if embraced with an attitude of openness to learning. We found that exposing our own research plans to scrutiny resulted in changes to the intervention design that gained the confidence of different stakeholders. Our understanding of the methods used, and their consequences, may be bounded by the person-centred nature of this particular intervention.

Factors affecting primary care practitioners' alcohol-related discussions with older adults: a qualitative study

BACKGROUND

Risk of harm from drinking is heightened in later life, owing to age-related sensitivities to alcohol. Primary care services have a key role in supporting older people (aged ≥50 years) to make healthier decisions about alcohol.

AIM

To examine primary care practitioners' perceptions of factors that promote and challenge their work to support older people in alcohol risk-reduction.

DESIGN AND SETTING

Qualitative study consisting of semi-structured interviews and focus groups with primary care practitioners in Northern England.

METHOD

Thirty-five practitioners (GPs, practice/district nurses, pharmacists, dentists, social care practitioners, and domiciliary carers) participated in eight interviews and five focus groups. Data were analysed thematically, applying principles of constant comparison.

RESULTS

Practitioners highlighted particular sensitivities to discussing alcohol among older people, and reservations about older people's resistance to making changes in old age; given that drinking practices could be established, and promote socialisation and emotional wellbeing in later life. Age-related health issues increased older people's contact with practitioners, but management of older people's long-term conditions was prioritised over discussion of alcohol. Dedicated time to address alcohol in routine consultations with older people and training in alcohol intervention facilitated practitioners, particularly pharmacists and practice nurses.

CONCLUSION

There are clear opportunities to support older people in primary care to make healthier decisions about alcohol. Dedicated time to address alcohol, training in identification of alcohol-related risks (particularly those associated with old age), and tailored interventions for older people, feasible to implement in practice settings, would help primary care practitioners to address older people's alcohol use.

Critical Role of General Practitioners in Preventing Readmission Following Emergency Department Alcohol Screening and Brief Intervention Management of Alcohol-Related Problems

Introduction/Objectives:

Alcohol screening and brief intervention (ASBI) strategies are useful in general practice (GP) but their effectiveness in the emergency department (ED) is unclear. We evaluated the effect of ED-based ASBI on re-admissions.

Methods:

453 ED subjects exceeding the threshold score on the three-item Alcohol Use Disorders Identification Test-Consumption (females 3+: males 4+) were randomized. We conducted telephone follow-up at 1 and 3 months and recorded hospital events 6 months pre- and post-enrolment.

Results:

Median weekly alcohol use was 20 standard drinks (interquartile range (IQR) 9-45) on enrolment. After 3 months, 247 (55%) were able to be re-interviewed. Median alcohol use was 10 drinks (IQR 4-26). Six months later, subjects receiving ED-ASBI without GP follow-up had significantly greater risk of re-admission compared with those having GP follow-up (OR 1.68, 95%CI 1.06-2.65; P = .028).

Conclusions:

ASBI reduces the likelihood of ED re-presentation only in subjects who have GP follow-up. The study has been registered as a clinical trial (Australian and New Zealand Clinical Trial Registry ACTRN12617001254381).

Effects of a brief alcohol intervention addressing the full spectrum of drinking in an adult general population sample: a randomized controlled trial

BACKGROUND AND AIMS

Evidence for efficacy of brief alcohol interventions (BAIs) is mainly limited to primary care and at-risk drinkers. The aim was to test the efficacy of a BAI addressing the full spectrum of alcohol use in a general population sample and across alcohol risk groups.

DESIGN

Two-parallel-group randomized controlled trial (allocation ratio 1:1) with post-baseline assessments at months 3, 6 and 12.

SETTING

One municipal registry office in Germany responsible for registration, passport and vehicle admission issues.

PARTICIPANTS

A total of 1646 proactively recruited 18-64-year-old adults with past year alcohol use (56% women, 66% low-risk drinkers) were randomized to intervention (n = 815) or control (n = 831).

INTERVENTION AND COMPARATOR

The intervention consisted of assessment plus computer-generated individualized feedback letters at baseline and months 3 and 6. Comparator was assessment only.

MEASUREMENTS

Primary outcome was change in the self-reported number of drinks/week from baseline to 12 months. Changes at 3 and 6 months were secondary outcomes. Moderator was alcohol risk group (low-risk versus at-risk drinking) according to the Alcohol Use Disorders Identification Test-Consumption, with scores from 1-3 (women) and from 1-4 (men) indicating low-risk drinking.

FINDINGS

For the whole sample, significant group differences were observed neither at 12-month follow-up [incidence rate ratio (IRR) = 1.01, 95% confidence interval (CI) = 0.87-1.17, Bayes factor (BE) = 0.52] nor at previous assessments (month 3: IRR = 1.01, 95% CI = 0.92-1.12, BE = 0.41; month 6: IRR = 0.93, 95% CI = 0.81-1.07, BE = 1.10). Moderator analyses revealed that low-risk drinkers were more likely to benefit from BAI only at month 6 than at-risk drinkers (IRR = 0.77, 95% CI = 0.70-0.86).

CONCLUSIONS

In a randomized controlled trial, there was no clear evidence for efficacy of a computer-based brief alcohol intervention in a general population sample, but there was some evidence of medium-term benefits in the large but understudied group of low-risk drinkers.

Reimagining brief interventions for alcohol: towards a paradigm fit for the twenty first century? : INEBRIA Nick Heather Lecture 2019: This lecture celebrates the work of Nick Heather in leading thinking in respect of both brief interventions and wider alcohol sciences

Background

There is no longer support for the idea that brief intervention programmes alone can contribute meaningfully to the improvement of population health relating to alcohol. As a result, calls for major innovations and paradigm shifts grow, notably among research leaders.

This paper briefly examines the history of the development of the evidence-base from the landmark World Health Organisation projects on Screening and Brief Intervention (SBI) in the 1980s onwards. Particular attention is given to weaknesses in the theorisation of social influence and interventions design, and declining effect sizes over time. Although the old SBI paradigm may be exhausted where it has been applied, it has not been replaced by a new paradigm. Alcohol marketing encourages heavy drinking and today may have more powerful effects on thinking about alcohol, and about alcohol problems, than previously. The nature of the societal challenge being faced in an alcogenic environment in which alcohol is widely promoted and weakly regulated underpins consideration of the possibilities for contemporary evidence-informed public health responses. Evidence-informed perspectives in discourses on alcohol problems need to be strengthened in redeveloping rationales for brief interventions. This process needs to move away from sole reliance on a model based on a two-person discussion of alcohol, which is divorced from wider concerns the person may have. Reimagining the nature of brief interventions involves incorporating digital content, emphasising meso-level social processes based on material that people want to share, and seeking synergies with macro-level population and media issues, including alcohol policy measures.

Conclusions

Current versions of brief interventions may be simply too weak to contend with the pressures of an alcogenic environment. A new generation of brief interventions could have a key role to play in developing multi-level responses to the problems caused by alcohol.

Text messaging interventions for reducing alcohol consumption among risky drinkers: systematic review and meta-analysis

BACKGROUND AND AIMS

The global growth of mobile phone use has led to new opportunities for health interventions, including through text messaging. We aimed to estimate the effects of text messaging interventions on alcohol consumption among risky drinkers.

METHODS

Systematic review and meta-analysis of reports on randomized controlled trials (RCTs) published in English. Searches were conducted on 23 May 2019 in PubMed; PubMed Central; CENTRAL; CDSR; DARE; NHS-EED; Scopus; PsycINFO; PsycARTICLES; CINAHL; and Web of Science. Measurements included number of episodes of heavy drinking (HED) per month and weekly alcohol consumption (WAC) in grams. Trials among risky drinkers who were not receiving co-interventions were included in the review (n = 3481, mean age 29 years, 41% female). Data were extracted from reports and authors were contacted for additional data.

RESULTS

Ten trials were included and all analyses were based on random-effects models. Primary analyses, including seven trials (n = 2528) for HED and five trials (n = 2236) for WAC, found that the interventions may reduce self-reported HED [-0.33 episodes per month; 95% confidence interval (CI) = -0.79, 0.12] and WAC (-18.62 g per week; 95% CI = -39.61, 2.38), although both estimates included the null. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) quality of evidence was judged to be low for both HED and WAC, primarily due to risk of attrition and performance bias, heterogeneity and influence of pilot trials on estimates.

CONCLUSIONS

Text messaging alcohol interventions may reduce alcohol consumption compared with no or basic health information; however, there are doubts about the overall quality of the evidence.

Exploratory Validation Study of the Individual AUDIT-C Items among Older People

AIMS

The AUDIT-C is a brief and commonly used alcohol screening tool, with few data available on the relative validity of the three individual items in older adult populations. The aim of this study was to explore the validity of the AUDIT-C items in identifying unhealthy drinking among older people, with a view to developing a single-item screener.

METHODS

A sample of 143 older adults (mean age = 71) were recruited from non-clinical settings in the UK. AUDIT-C scores were compared to an unhealthy drinking reference category of consuming more than the UK recommended weekly units of alcohol. Standard analyses were conducted for men and women, and for those prescribed medications for long term conditions.

RESULTS

The AUDIT-C items performed well in identifying unhealthy drinking in this sample of older people, with generally high sensitivity, specificity and area under the ROC curve. No significant differences were found in the validity of the three items, though the combined sensitivity and specificity scores and ROC values for item 3 were consistently slightly lower than for items 1 and 2. The findings were similar for men and women, and for participants prescribed medications for long-term conditions.

CONCLUSIONS

AUDIT-C items 1 and 2 performed as well as item 3 in identifying unhealthy drinking among older people in this study. Both are reasonable single-item screener candidates, especially given relative ease of administration, with further validation study needed to examine psychometrics and how alcohol screening for older people can best be implemented in clinical settings.

Treating alcohol use disorders in primary care - a qualitative evaluation of a new innovation: the 15-method

OBJECTIVE

This study aims to explore how the characteristics of an innovation, the 15-method, a stepped care model for treatment of alcohol use disorders in primary care was perceived.

METHODS/DESIGN/SETTING/SUBJECT

General practitioners and heads of primary care units (n = 10) that delivered the 15-method in a randomized controlled trial participated in individual interviews at two occasions in Stockholm, Sweden. Data were analyzed with theoretical thematic analysis, using Diffusion of Innovation Theory.

RESULTS

The participants described that offering the 15-method met a need among their patients. Participants were positive towards the training and the manual for the method. They mentioned a previous lack of routines to work with alcohol use disorders. The 15-method was described as easy to use. It would however be more feasible to implement in a team of different professions, rather than among general practitioners only. Priorities made by regional health care managers were described as important for the implementation, as well as financial incentives. A barrier to implementation was that alcohol screening was perceived as difficult. While the 15-method was perceived as effective in reducing the patients' alcohol use and cost effective, participants expressed uncertainty about the long-term effects.

CONCLUSIONS

The 15-method provides structure for treatment of alcohol use disorders and is described by general practitioners and heads as a promising approach. Being able to offer treatment for alcohol dependence may increase the uptake of alcohol interventions in primary care.KEY POINTSLittle attention has been given to develop treatment models for alcohol use disorders that are adapted to primary care settings.This study describes how an innovation, the 15-method, a stepped care model for treatment of alcohol use disorders in primary care was perceived.The 15-method provides structure for treatment of alcohol use disorders in primary care and is described by general practitioners and heads as a promising approach.Being able to offer treatment for alcohol dependence may increase the uptake of alcohol interventions in primary care.

Introducing alcohol as a drug in medicine reviews with pharmacists: Findings from a co-design workshop with patients

INTRODUCTION

Alcohol poses a range of potential problems to people taking medications, but health professionals are usually not comfortable talking about drinking with patients. The Medicines and Alcohol Consultation aims to increase the capacity of pharmacists to conduct person-centred reviews in which alcohol is regarded as another drug to be discussed alongside medications. This paper explores sensitivities in discussing alcohol and views on the legitimacy of the Medicines and Alcohol Consultation intervention concept at a pharmacy-user intervention co-design workshop.

METHODS

A co-design workshop was held with 14 people recruited from UK community pharmacies who regularly drank alcohol and took medications for long-term conditions. This formed one element of a broader, iterative, intervention co-production process. Workshop discussions were audio-recorded and analysed thematically.

RESULTS

The basic intervention concept resonated well, though not entirely unproblematically. Participants were interested in receiving information on how medications interact with alcohol and how this might affect their own conditions, with which to make their own informed choices. Linking alcohol use to medicines gave legitimacy to pharmacists to raise alcohol in medicines reviews. Sensitivity in talking about alcohol was linked to vulnerability to negative judgement.

DISCUSSION AND CONCLUSIONS

Changing the framing of alcohol in medicines reviews, away from being regarded as a 'lifestyle issue' to being considered a drug directly linked to medicines use, safety and effectiveness, was welcomed by participants in this study.

Process study within a pilot cluster randomised trial in community pharmacy: An exploration of pharmacist readiness for research

INTRODUCTION

Community pharmacies have an increasingly prominent public health function. This includes addressing alcohol, but guidance on delivery of alcohol interventions in this setting is lacking. We have developed an intervention that integrates attention to alcohol within existing community pharmacy medicine review services. This paper examines the experiences of community pharmacists (CPs) in conducting a pilot trial of the intervention, including the acceptability of the trial patient recruitment procedures and the training and support provided by the research team.

METHOD

The pilot trial was conducted in 10 community pharmacies in Yorkshire, England. One CP from each pharmacy was recruited via a multi-stage process to assess motivation, commitment and capacity to participate. Each CP attended a research training day and received on-going research support to conduct the trial. Semi-structured audio-recorded face-to-face interviews (lasting 40-105 min) were conducted with all the CPs at the end of the trial. Data were also available from three direct observations conducted during trial support visits. Data were analysed thematically.

RESULTS

The CPs were supportive of research in community pharmacy but had little direct experiences of research themselves. They valued the training and support provided, which had quickly identified areas where CPs were deviating from the study recruitment protocol. In some instances, the boundaries between research and practice became blurred with CPs making changes to their usual routines and interactions with patients to accommodate the research.

CONCLUSIONS

The trial procedures were acceptable to CPs, in part because of the training and support provided. There are also identifiable areas where CPs' readiness for research could be enhanced to facilitate participation in future trials in this setting.

Factors influencing the implementation of screening and brief interventions for alcohol use in primary care practices: a systematic review using the COM-B system and Theoretical Domains Framework

BACKGROUND

Alcohol is a leading risk factor contributing to the global burden of disease. Several national and international agencies recommend that screening and brief interventions (SBI) should be routinely delivered in primary care settings to reducing patients' alcohol consumption. However, evidence shows that such activities are seldom implemented in practice. A review of the barriers and facilitators mediating implementation, and how they fit with theoretical understandings of behaviour change, to inform the design of implementation interventions is lacking. This study aimed to conduct a theory-informed review of the factors influencing general practitioners' and primary care nurses' routine delivery of alcohol SBI in adults.

METHODS

A systematic literature search was carried out in four electronic databases (Medline, CINAHL, CENTRAL, PsycINFO) using comprehensive search strategies. Both qualitative and quantitative studies were included. Two authors independently abstracted and thematically grouped the data extracted. The barriers and facilitators identified were mapped to the domains of the Capability-Opportunity-Motivation-Behaviour system/Theoretical Domains Framework (TDF).

RESULTS

Eighty-four out of the 258 studies identified met the selection criteria. The majority of the studies reported data on the views of general practitioners (n = 60) and used a quantitative design (n = 49). A total of 660 data items pertaining to barriers and 253 data items pertaining to facilitators were extracted and thematically grouped into 46 themes. The themes mapped to at least one of the 14 domains of the TDF. The three TDF domains with the highest number of data units coded were 'Environmental Context and Resources' (n = 158, e.g. lack of time), 'Beliefs about Capabilities' (n = 134, e.g. beliefs about the ability to deliver screening and brief advice and in helping patients to cut down) and 'Skills' (n = 99, e.g. lack of training).

CONCLUSIONS

This study identified a range of potential barriers and facilitators to the implementation of alcohol SBI delivery in primary care and adds to the scarce body of literature that identifies the barriers and facilitators from a theoretical perspective. Given that alcohol SBI is seldom implemented, this review provides researchers with a tool for designing novel theory-oriented interventions to support the implementation of such activity.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016052681.

Integrating Videoconferencing into Primary Care to Address Alcohol Use Disorder

This commentary on Leibowitz et al, "Video Consultation to Increase Treatment of Alcohol Use Disorder in Primary Care: A Pilot Feasibility Study" highlights the potential value of utilizing videoconferencing to address unhealthy drinking in primary care settings, the advantages of centralized expert consultants that may be accessed through technology, and the need for future implementation process and clinical care outcome research.

Managing older people's perceptions of alcohol-related risk: a qualitative exploration in Northern English primary care

BACKGROUND

Risk of harm from drinking increases with age as alcohol affects health conditions and medications that are common in later life. Different types of information and experiences affect older people's perceptions of alcohol's effects, which must be navigated when supporting healthier decisions on alcohol consumption.

AIM

To explore how older people understand the effects of alcohol on their health; and how these perspectives are navigated in supportive discussions in primary care to promote healthier alcohol use.

DESIGN AND SETTING

A qualitative study consisting of semi-structured interviews and focus groups with older, non-dependent drinkers and primary care practitioners in Northern England.

METHOD

A total of 24 older adults aged ≥65 years and 35 primary care practitioners participated in interviews and focus groups. Data were analysed thematically, applying principles of constant comparison.

RESULTS

Older adults were motivated to make changes to their alcohol use when they experienced symptoms, and if they felt that limiting consumption would enable them to maintain their quality of life. The results of alcohol-related screening were useful in providing insights into potential effects for individuals. Primary care practitioners motivated older people to make healthier decisions by highlighting individual risks of drinking, and potential gains of limiting intake.

CONCLUSION

Later life is a time when older people may be open to making changes to their alcohol use, particularly when suggested by practitioners. Older people can struggle to recognise potential risks or perceive little gain in acting on perceived risks. Such perceptions may be challenging to navigate in supportive discussions.

Effect of "motivational interviewing" and "information, motivation, and behavioral skills" counseling interventions on choosing the mode of delivery in pregnant women: a study protocol for a randomized controlled trial

BACKGROUND

Cesarean section is an important surgical procedure, when normal vaginal delivery imposes a risk to mother and/or baby. The World Health Organization states the ideal rate for Cesarean section to be between 10 and 15% of all births. In recent decades, the rate has been increased dramatically worldwide. This paper explains the protocol of a randomized controlled trial that aims to compare the effect of "motivational interviewing" and "information, motivation, and behavioral skills" counseling interventions on choosing mode of delivery in pregnant women.

METHODS

A four-armed, parallel-design randomized controlled trial will be conducted on pregnant women. One hundred and twenty women will be randomly assigned to four groups including three intervention groups and one control group. The intervention groups included the following: (1) motivational interviewing; (2) face-to-face information, motivation, and behavioral skills model; and (3) information, motivation, and behavioral skills model provided using a mobile application. The inclusion criteria include being literate, being in gestational age from 24 to 32 weeks, being able to speak Persian, having no complications in the current pregnancy, having no indications for Cesarean section, and having enough time to participate in the intervention. The primary outcome of the study is the mode of delivery. The secondary outcomes are women's intention to undergo Cesarean section and women's self-efficacy.

DISCUSSION

The interventions of this protocol have been programmed to reduce unnecessary Cesarean sections. Findings may contribute to a rise in normal vaginal delivery, and the effective intervention may be extended for use in national Cesarean section plans.

TRIAL REGISTRATION

Iran Randomized Clinical Trial Center IRCT20151208025431N7 . Registered on December 07, 2018.

A pilot cluster randomised trial of the medicines and alcohol consultation (MAC): an intervention to discuss alcohol use in community pharmacy medicine review services

Background

Alcohol interventions are important to the developing public health role of community pharmacies. The Medicines and Alcohol Consultation (MAC) is a new intervention, co-produced with community pharmacists (CPs) and patients, which involves a CP practice development programme designed to integrate discussion of alcohol within existing NHS medicine review services. We conducted a pilot trial of the MAC and its delivery to investigate all study procedures to inform progression to a definitive trial.

Methods

This cluster pilot RCT was conducted in 10 community pharmacies in Yorkshire, UK, with a CP from each who regularly conducted Medicine Use Review (MUR) and New Medicine Service (NMS) consultations. Randomisation was conducted using a secure remote randomisation service. Intervention CPs (n = 5) were trained to deliver the MAC in MUR/NMS consultations. Control CPs (n = 5) provided these services as usual. Consecutive MUR/NMS patients were asked by CPs to participate, screened for eligibility (consumption of alcohol at least twice per week), and baseline data collected for those eligible. A two-month follow-up telephone interview was conducted. Blinding of CPs was not possible, but patients were blinded to the alcohol focus of the trial. Primary outcomes were total weekly UK units (8 g of ethanol per unit) of alcohol consumption in the week prior to follow-up, and confidence in medications management. Trial procedures were assessed by recruitment, attrition, and follow-up rates.

Results

260 patients were approached by CPs to take part in the trial, 68% (n = 178) were assessed for eligibility and 30% (n = 54) of these patients were eligible. Almost all eligible patients (n = 51; 94%) consented to participate, of whom 92% (n = 47) were followed-up at 2 months; alcohol consumption was lower in the intervention arm and confidence in medication management reduced slightly for both groups. Exploration of recall issues at follow-up showed a high level of agreement between a two-item quantity/frequency measure and 7-day guided recall of alcohol consumption.

Conclusions

The pilot trial demonstrates the feasibility of implementing the MAC in community pharmacy and trial recruitment and data collection procedures. However, decommissioning of MURs means that it is not possible to conduct a definitive trial of the intervention in this service.

Trial registration

ISRCTN57447996

Sick days in general hospital patients two years after brief alcohol intervention: Secondary outcomes from a randomized controlled trial

Little is known about the long-term impact of brief alcohol interventions (BAIs) on health and on sick days in particular. The aim was to investigate whether BAIs reduce sick days in general hospital patients over two years, and whether effects depend on how BAIs are delivered; either through in-person counseling (PE) or computer-generated written feedback (CO). To investigate this, secondary outcome data from a three-arm randomized controlled trial with 6-, 12-, 18- and 24-month follow-ups were used. The sample included 960 patients (18-64 years) with at-risk alcohol use identified through systematic screening on 13 hospital wards. Patients with particularly severe alcohol problems were excluded. Participants were allocated to PE, CO and assessment only (AO). Both interventions were tailored according to behavior change theory and included three contacts. Self-reported number of sick days in the past 6 months was assessed at all time-points. A zero-inflated negative binomial latent growth model adjusted for socio-demographics, substance use related variables and medical department was calculated. In comparison to AO, PE (OR = 2.18, p = 0.047) and CO (OR = 2.08, p = 0.047) resulted in statistically significant increased odds of reporting no sick days 24 months later. Differences between PE and CO, and concerning sick days when any reported, were non-significant. This study provides evidence for the long-term efficacy of BAIs concerning health, and concerning sick days in particular. BAIs have the potential to reduce the occurrence of sick days over 2 years, independent of whether they are delivered through in-person counseling or computer-generated written feedback.

Brief motivational therapy versus enhanced usual care for alcohol use disorders in primary care in Chile: study protocol for an exploratory randomized trial

BACKGROUND

Harmful alcohol use is a leading cause of global disability and death. However, increased detection and brief intervention capacity of more severe alcohol use disorders has not been accompanied by increased availability of treatment services. Incorporating treatment for such disorders into primary care is of paramount importance for improving access and health outcomes. This study aims to estimate the effectiveness of a Brief Motivational Treatment (BMT) applied in primary care for treatment of these disorders.

METHODS

A parallel-group, single-blinded, severity-stratified, randomized clinical trial will test the superiority of BMT over enhanced usual care. Eligible participants will be those seeking treatment and who fulfill DSM-V criteria for alcohol use disorder and criteria for harmful alcohol use. With an estimated a loss to follow-up of 20%, a total of 182 participants will be recruited and equally randomized to each treatment group. The intervention group will receive an adaptation of the motivational enhancement therapy, as manualized in Project MATCH. This treatment consists of four 45-min sessions provided by a general psychologist with at least 3 years of primary care experience. The primary outcome is the change from baseline in the drinks per drinking day during the last 90 days, which will be captured using the Timeline Follow Back method. Secondary outcomes will describe the changes in alcohol use pattern, motivational status, and severity of the disorder. All participants will be analyzed according to the group they were allocated, regardless of the treatment actually received. Mean differences (MD) will be computed for continuous outcomes and relative risks (RR) and RR reductions (RRR) for dichotomous results. Linear models will deliver the subgroup analyses. Missingness is assumed to be associated with the baseline alcohol use pattern and severity, so a multiple imputation method will be used to handle missing data.

DISCUSSION

This trial aims to test the superiority of BMT over enhanced usual care with a reasonable superiority margin, over which the BMT could be further considered for incorporation into PC in Chile. Its pragmatic approach ultimately aims to inform policymakers about the benefit of including a brief psychosocial treatment into PC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04345302 . Registered on 28 April 2020.

'I'm not a real boozer': a qualitative study of primary care patients' views on drinking and its consequences

BACKGROUND

The public health message around alcohol is complex, with benefits versus harms, the confusing concept of risk and drinking guidance changing over time. This provides a difficult context for alcohol screening in primary care, with established barriers from the practitioner perspective, but less is known about the patients' perspective. This study explores patients' views on drinking.

METHODS

Eligible participants were recorded as drinking above low risk levels in primary care. Six practices in North London participated. Interviews were in-depth, semi-structured, transcribed verbatim and underwent detailed thematic analysis.

FINDINGS

Interviews were conducted with 8 women and 12 men, aged 26-83 years, mostly educated to undergraduate level and of 'White' ethnicity. UK drinking guidance was viewed as irrelevant for reasons related to life stage, lifestyle and absence of harm. Dependence, loss of functionality and control were perceived as key features of problematic drinking. Healthy lifestyles, in terms of diet, exercise and not smoking, were thought to mitigate potential problems associated with alcohol intake.

CONCLUSION

The findings suggest that public health messages and brief advice should focus on harm experienced at different life stages, among people with different lifestyles, to challenge the ubiquitous view that 'I'm not a real boozer'.

Should GPs ask patients about their financial concerns? Exploration through collaborative research

Objective: Health services should arguably be concerned about the financial situation of patients since health problems can cause financial concerns, which in turn can cause health problems. In this study, we explored the role of the general practitioner (GP) as a potential early discoverer of financial problems who can refer at-risk patients to financial counselling services.Design: A collaborative health service research experiment. For four weeks, GPs asked their patients predefined questions about financial concerns and health, by anonymous data mapping. GPs shared their experiences with the researchers after the experiment.Setting: One GP office in Norway.Subjects: A total of 565 patients were included in data mapping by 8 GPs.Main outcome measures: Patient prevalence data and GPs experimental data of patients' health problems that caused financial concerns and financial concerns that affected patients' health.Results: Of 565 GP patients, 11% (n = 63) indicated that they had health problems causing them financial concerns, or vice versa; 9% of patients reported health problems causing financial concerns and 8% of patients reported financial concerns that affected their health. Through the data mapping experiment GPs became aware of financial concerns of their patients and by this expanded and improved their therapeutic toolbox. Several months after the experiment the GPs reported that more patients received financial counselling since the GPs asked their patients about financial problems more often than before and because the patients had heard that GPs cared about such problems.Conclusion: Our results suggest that GPs can be early discoverers of financial problems interacting with their patients' health. When there are no clear medical explanations for the health problems that prompted the consultation, the best therapy may thus be financial counselling.Key pointsMany people live on the edge of financial ruin and struggle to keep track of their finances, but limited research exists that investigates associations between finance and health.In a collaborative health services research experiment 11% of the patients at a Norwegian GP office had health problems that caused them financial concerns, or vice versa.GPs found it helpful to ask patients about their financial concerns when no clear medical explanations for their health problems was found. Then free financial counselling services could be offered.

Identification of Gambling Problems in Primary Care: Properties of the NODS-CLiP Screening Tool

INTRODUCTION

There are several brief screening tools for gambling that possess promising psychometric properties, but have uncertain utility in generalist healthcare environments which prioritize prevention and brief interventions. This study describes an examination of the National Opinion Research Centre Diagnostic and Statistical Manual of Mental Disorders Screen for Gambling Problems (NODS-CLiP), in comparison with the Problem Gambling Severity Index (PGSI), when used to operationalize gambling problems across a spectrum of severity.

METHODS

Data were obtained from 1058 primary care attendees recruited from 11 practices in England who completed various measures including the NODS-CLiP and PGSI. The performance of the former was defined by estimates of sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs), when PGSI indicators of problem gambling (5+) and any gambling problems (1+), respectively, were reference standards.

RESULTS

The NODS-CLiP demonstrated perfect sensitivity for problem gambling, along with high specificity and a NPV, but a low PPV. There was much lower sensitivity when the indicator of any gambling problems was the reference standard, with capture rates indicating only 20% of patients exhibiting low to moderate severity gambling problems (PGSI 1-4) were identified by the NODS-CLiP.

CONCLUSIONS

The NODS-CLiP performs well when identifying severe cases of problem gambling, but lacks sensitivity for less severe problems and may be unsuitable for settings which prioritize prevention and brief interventions. There is a need for screening measures which are sensitive across the full spectrum of risk and severity, and can support initiatives for improving identification and responses to gambling problems in healthcare settings such as primary care.

Electronic self-administered screening for substance use in adult primary care patients: feasibility and acceptability of the tobacco, alcohol, prescription medication, and other substance use (myTAPS) screening tool

BACKGROUND

The TAPS Tool is a substance use screening and brief assessment instrument that was developed for use in primary care medical settings. It is one of the first screening instruments to provide rapid assessment of all commonly used substance classes, including illicit and prescription opioids, and is one of the only available screeners designed and validated in an electronic self-administered format (myTAPS). This secondary analysis of data from the TAPS Tool validation study describes the feasibility and acceptability of the myTAPS among primary care patients.

METHODS

Adult patients (N = 2000) from five primary care clinics completed the TAPS Tool on a tablet computer (myTAPS), and in an interviewer-administered format. Requests for assistance and time required were tracked, and participants completed a survey on ease of use, utilization of audio guidance, and format preference. Logistic regression was used to examine outcomes in defined subpopulations, including groups that may have greater difficulty completing an electronic screener, and those that may prefer an electronic self-administered approach.

RESULTS

Almost all participants (98.3%) reported that the myTAPS was easy to use. The median time to complete myTAPS screening was 4.0 min (mean 4.48, standard deviation 2.57). More time was required by participants who were older, Hispanic, Black, or reported non-medical prescription drug use, while less time was required by women. Assistance was requested by 25% of participants, and was more frequently requested by those who with lower education (OR = 2.08, 95% CI 1.62-2.67) or age > 65 years (OR = 2.79, 95% CI 1.98-3.93). Audio guidance was utilized by 18.3%, and was more frequently utilized by participants with lower education (OR = 2.01, 95% CI 1.54-2.63), age > 65 years (OR = 1.79, 95% CI 1.22-2.61), or Black race (OR = 1.30, 95% 1.01-1.68). The myTAPS format was preferred by women (OR = 1.29, 95% CI 1.00-1.66) and individuals with drug use (OR = 1.43, 95% CI 1.09-1.88), while participants with lower education preferred the interviewer-administered format (OR = 2.75, 95% CI 2.00-3.78).

CONCLUSIONS

Overall, myTAPS screening was feasible and well accepted by adult primary care patients. Clinics adopting electronic screening should be prepared to offer assistance to some patients, particularly those who are older or less educated, and should have the capacity to use an interviewer-administered approach when required.

Interventions to Reduce Unhealthy Alcohol Use among Primary Care Patients with HIV: the Health and Motivation Randomized Clinical Trial

BACKGROUND

Unhealthy alcohol use has adverse effects on HIV treatment. Screening, brief intervention, and referral to treatment (SBIRT) has some evidence of efficacy but may not be sufficient for those with low motivation or comorbid substance use.

OBJECTIVE

To examine the effectiveness of motivational interviewing (MI) and emailed feedback (EF) among primary care HIV-positive patients, compared with treatment as usual care (UC) only, which included SBIRT.

DESIGN

Randomized clinical trial.

PARTICIPANTS

Six hundred fourteen adult HIV-positive patients in Kaiser Permanente Northern California who reported prior-year unhealthy alcohol use.

INTERVENTION

Participants were randomized to either three sessions of MI (one in person and two by phone), information regarding alcohol risks via EF through a patient portal, or UC alone. MI and EF participants who reported unhealthy alcohol use at 6 months were offered additional MI and EF treatment, respectively.

MAIN MEASURES

Participant-reported unhealthy alcohol use (defined as ≥ 4/≥ 5 drinks per day for women/men), alcohol problems at 12 months, based on blinded telephone interviews. Secondary outcomes included drug use and antiretroviral (ART) adherence.

KEY RESULTS

At 12 months, there were no overall group differences, but in all three arms, there were declines in unhealthy alcohol use and alcohol-related problems (p < 0.001). Participants reporting low motivation to reduce drinking at baseline were less likely to report unhealthy alcohol use if they received MI vs. EF and UC (p = 0.013). At 6 months, reported illegal drug use/misuse of prescription drugs other than marijuana was lower in the MI arm than EF or UC (p = 0.012). There were no differences in ART adherence between groups.

CONCLUSIONS

In a randomized trial of HIV-positive patients using two behavioral interventions compared with SBIRT alone, participants in all three conditions reduced unhealthy alcohol use. MI may provide added benefit for patients with low motivation or who report illegal drug use/misuse of prescription drugs.

TRIAL REGISTRATION

NCT01671501 ( ClinicalTrials.gov ).